Extracorporeal gas exchange: when to start and how to end?

Gattinoni, Luciano; Vassalli, Francesco; Romitti, Federica; Vasques, Francesco; Pasticci, Iacopo; Duscio, Eleonora; Quintel, Michael

doi:10.1186/s13054-019-2437-2

Cited by 37 publications

(33 citation statements)

References 40 publications

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“…Compared to the several trials addressing the safety and efficacy of ECMO in severe ARDS [1–4], the body of literature regarding ECMO weaning is remarkably scarce. Therefore, this essential component of the management of patients on ECMO is highly variable and often lacks of a systematic approach [5], analogously to the weaning protocols and spontaneous breathing trials used for liberation from mechanical ventilation [6].…”

Section: Introductionmentioning

confidence: 99%

“…In between these two phases is a continuum of lung healing, during which lung function becomes sufficient to maintain a gas exchange compatible with life, but at the expenses of a high respiratory drive and large swings in transpulmonary pressures. In these conditions, ECMO has the role of maintaining lung protection partially contributing to the patient’s gas exchange [5]. In the effort to track the progress of an individual patient along this imaginary line, it is necessary to measure the relative contribution of the membrane and native lungs in terms of gas exchange, as well as the response of the patient’s respiratory drive and mechanics to the variation in ECMO settings.…”

Section: Introductionmentioning

confidence: 99%

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How I wean patients from veno-venous extra-corporeal membrane oxygenation

et al. 2019

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

How I wean patients from veno-venous extra-corporeal membrane oxygenation

et al. 2019

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“…9,13 The weaning of patients from VV-ECMO support, relies on the detection of improvements native respiratory function, which is complicated by the fact that measures such as arterial oxygenation are directly influenced by the high fraction of inspired oxygen delivered during VV-ECMO and native lung function. 14 The measurement of lung mechanics at the bedside relies on the absence of patient spontaneous breathing. However, mechanical ventilator strategies during ECMO often use pressure control modes.…”

Section: Discussionmentioning

confidence: 99%

Lung ultrasound score as an indicator of dynamic lung compliance during veno-venous extra-corporeal membrane oxygenation

2020

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Decisions on weaning from veno-venous extra-corporeal membrane oxygenation (VV-ECMO) requires the ability to maintain adequate gas exchange and work of breathing with reductions in ECMO pump flow and fresh gas flow. Testing of the readiness to wean the patient from ECMO however may vary dependent upon local protocols and clinical judgment. This study sought to validate the use of the LUS-score during VV-ECMO against the changes in chest x-ray infiltrates, dynamic lung compliance (CLdyn) and VV-ECMO settings (as standard measures of native lung function and the level of ECMO support) during the ECMO cycle. This prospective cohort study of 10 patients on VV-ECMO compared the LUS score (range 0–36) within 48-h, day 5 and day 10 of commencement of ECMO (or on the day of ECMO decannulation) to dynamic lung compliance, Murray Lung Injury Score and ECMO settings. Seven Male and three Female patients were included (average age 37 years (SD 14.8) and weight 71 Kg (SD 16.9). Median (IQR) duration of ECMO, ICU and hospital length of stay was 7.5 days (5.2–19.0), 12.5 days (8.5–22.7), 19.0 days (12.1– 36.1), respectively. There was a strong negative association between LUS-score and dynamic lung compliance (rs(33) = –0.66, p < .001) providing some validation on the use of the LUS score as a potential surrogate measure of lung aeration and lung mechanics during VV-ECMO weaning.

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“…Finally, there is the problem of carbon dioxide removal which we have not addressed in this study. It appears likely that, given the high di usivity of carbon dioxide compared to oxygen under most circumstances, carbon dioxide will be eliminated su ciently (7). Indeed, it may even require some carbon dioxide in the fresh gas stream to avoid eliminating CO2 too rapidly, however this would need to be studied by examining CO2 transfer in much the same way as we studied oxygen transfer.…”

Section: Discussionmentioning

confidence: 99%

Toward respiratory support of critically ill COVID-19 patients using repurposed kidney hollow fiber membrane dialysers to oxygenate the blood

Rubin

Stacey

Matambo

et al. 2020

Preprint

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The mass transfer characteristics for oxygen from the gas phase to blood in a hollow fiber renal dialysis unit was investigated in vitro with a view to using such devices to effect respiratory support in patients with viral pneumonia and acute respiratory distress syndrome. In our in vitro experiments, which were severely curtailed by prevailing circumstances, we used water as a substitute on the blood side. The water was saturated rapidly indicating that the system was flow limited rather than diffusion limited for oxygen transfer. Using these findings, we estimated the expected performance with blood and the results suggest that two dialysis units operating in parallel with a pure oxygen gas supply running counter-current to the blood flow, could supply up to 40% of the total required oxygen demand rate in an adult patient. While not studied, carbon dioxide elimination is likely to be feasible as well. It is thus possible that hollow fiber dialysis units operating with suitable roller pumps in a veno-venous access configuration, could serve as a cost-effective and readily available alternative or adjunct for respiratory support in the face of severe resource constraints. Verification and extension of our study is needed by well resourced laboratories who are still able to function during this unprecedented period of restrictions. If, after further studies and clinical considerations, this approach appears feasible, then consideration may be given to clinical deployment of this technique in desperate situations where no alternative exists to preserve life.

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Extracorporeal gas exchange: when to start and how to end?

Cited by 37 publications

References 40 publications

How I wean patients from veno-venous extra-corporeal membrane oxygenation

How I wean patients from veno-venous extra-corporeal membrane oxygenation

Lung ultrasound score as an indicator of dynamic lung compliance during veno-venous extra-corporeal membrane oxygenation

Toward respiratory support of critically ill COVID-19 patients using repurposed kidney hollow fiber membrane dialysers to oxygenate the blood

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